Model for Comprehensive Community and Home-based Health Care

SEA-Nurs-451 Distribution: General Model for Comprehensive Community and Home-based Health Care Report of a Regional Consultation Bangkok, Thailand, 2-4 December 2003 WHO Project: ICP OSD 002 World Health Organization Regional Office for South-East Asia New Delhi June 2004

World Health Organization (2004) This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors.

CONTENTS Page 1. INTRODUCTION...1 2. OBJECTIVES...2 3. INAUGURAL SESSION...3 4. NEED FOR COMMUNITY AND HOME-BASED HEALTH CARE SERVICES IN COUNTRIES OF THE REGION...4 5. OVERVIEW OF THE SEARO CCHBHC MODEL AND FIELD-TESTING PROCESS...6 6. EXPERIENCES IN FIELD-TESTING OF SEARO CCHBHC MODEL AND LESSONS LEARNED...9 6.1 Bhutan...9 6.2 Myanmar...16 6.3 Nepal...24 6.4 Thailand...32 6.5 Indonesia...40 7. FIELD VISITS...43 8. SUGGESTIONS FOR FURTHER REFINING AND FINALIZING THE MODEL, TAKING INTO ACCOUNT THE OUTCOMES OF THE FIELD TEST AND OTHER EXPERIENCES AT THE COUNTRY LEVEL...47 9. WAYS FORWARD TOWARDS PROMOTING THE ADAPTATION AND APPLICATION OF THE MODEL IN ORDER TO STRENGTHEN COMMUNITY HEALTH SERVICES IN COUNTRIES OF THE REGION...47 10. RECOMMENDATIONS...49 Annexes 1. List of Participants...51 2. Programme...54 Page iii

1. INTRODUCTION With the double burden of communicable and non communicable diseases, increase in health care costs and increase in the older population (up to 300%, according to WHO s recent estimates), there is a steep increase in the need for long-term and chronic care and care to manage daily living, in addition to strengthening basic health care services. Accessibility to health services has become an important issue, which countries of the South-East Asia Region (SEAR) need to address. This need is further emphasized by the continuing trend towards shortened hospital stays. Given the escalating costs of health services, the poor, the vulnerable and the disadvantaged groups (who normally have only limited access to health care) will be even more deprived. There is an urgent need, therefore, for countries of the Region to extend health services beyond hospital walls and establish an alternative to hospital care. This strategy will ensure the accessibility of health care as well as strengthen the continuum of care between the hospital and home. Most countries of the Region have established several community-based health care services, such as community based rehabilitation, community based care and support programmes for people living with HIV/AIDS (PLHA), community midwifery, community health nursing, community mental health and other community services for target diseases, e.g. childhood illnesses with the implementation of integrated management of childhood illnesses, and tuberculosis (TB) with the implementation of directly observed treatment short-course (DOTS) strategy. With few exceptions, many of these services, although integrated into the primary health care (PHC) structure, lack horizontal integration or proper coordination with other related key programmes. Therefore, there is a need to provide comprehensive and properly coordinated health services in support of an essential health care package at community level, because these services usually fall under the responsibility of the same core health workers. Page 1

Report of a Regional Consultation In light of the above, the South-East Asia Regional Office (SEARO) of WHO undertook the initiative for the development of a generic model for comprehensive community and home-based health care (CCHBHC) to provide direction to Member Countries on how they can further strengthen community health services in response to the changing health needs and services requirements of people in the Region. The Regional Office contracted the Joint WHO Collaborating Center for Nursing and Midwifery Development, Mahidol University, Thailand, through an Agreement for Performance of Work to develop such model using the services of a multidisciplinary working group. The model was developed in close collaboration with Member Countries. It was field-tested in 2001-2002 in Bhutan, Myanmar, Nepal and Thailand to assess its relevance and practicality within the regional context. Following the field test, a consultative meeting was convened in Bangkok, Thailand from 2-4 December 2003 to finalize the model and to advocate its application in countries of the Region. Eighteen participants, one special invitee, ten observers and seven members of the WHO Secretariat participated in the meeting. The List of Participants and Programme of the Meeting are at Annex 1 and 2 respectively. 2. OBJECTIVES The objectives of the consultation were to: (1) To critically review the process, outcomes (with special emphasis on core principles of the model, i.e. equity, quality, partnership, effectiveness and efficiency), and lessons learned of the field test of the SEARO CCHBHC model in Bhutan, Myanmar, Nepal and Thailand; (2) To finalize the CCHBHC model taking into account the field-test outcomes and other experiences at country level, and (3) To identify ways forward to promote the adaptation and application of the SEARO CCHBHC model in countries of the Region. Page 2

Model for Comprehensive Community and Home-based Health Care 3. INAUGURAL SESSION Professor Dr Srisin Khusmith, Vice President for Research, Mahidol University, welcomed the participants on behalf of the President of Mahidol University. She pointed out that this meeting was the second meeting facilitated by the Joint WHO Collaborating Centre for Nursing Midwifery Development, Mahidol University, with respect to the CCHBHC model. The first consultation meeting held in August 2001, had three distinctive outcomes: it identified good practices in community and home- based health services; it reviewed the proposed CCHBHC model, in terms of its practicality and relevance, and thirdly, it recommended further development and testing of the model. The address by Dr Uton Muchtar Rafei, Regional Director, WHO South- East Asia Region, was then read-out by Dr Bjorn Melgaard, WHO Representative to Thailand. The Regional Director noted that there was urgent need for countries of the Region to extend their health services beyond hospital walls. With increasing health care costs, the poor, vulnerable and disadvantaged groups of the population were further deprived. Therefore, there was an urgent need to introduce cost-effective care and support in communities and homes. It was further pointed out that this care and support could be carried out by less trained health personnel and/or family members, provided that proper supervision by qualified health personnel was provided. However, the importance of such care and support services to be horizontally integrated or properly coordinated with other related programmes at the PHC level, was further stressed, as they are usually carried out by the same health worker/s. In response to this challenge, the Regional Office therefore took initiative in 2001, in collaboration with the Joint WHOCC for Nursing and Midwifery Development, Mahidol University, Thailand, to develop a generic model for countries to provide comprehensive community and home-based health services. It was highlighted that the outcome of the field-testing of the model in Bhutan, Myanmar, Nepal and Thailand in 2001-2002 was encouraging. The participating countries had reported the model to be a useful tool in assisting them in better organizing and managing their community health services. This meeting would be an opportunity to learn more about how this model is seen Page 3

Report of a Regional Consultation by the countries of the Region as a tool to improve accessibility and quality of community health services. Dr Pakdi Pothisiri, Deputy Permanent Secretary, Ministry of Public Health, Thailand inaugurated the meeting on behalf of the Permanent Secretary. He pointed out that the work on CCHBHC model and related field-testing had been very contributive to improving the accessibility and quality of community health services as well as to enhancing the participation of individuals, families and communities for proper self care and healthy lifestyles. He further referred to the successful launching in Thailand of a universal coverage health care campaign, (including introduction of health promoting hospitals, the 30 Bahts scheme and primary care units) and expressed that the CCHBHC model would be both congruent to, and beneficial for this campaign. 4. NEED FOR COMMUNITY AND HOME-BASED HEALTH CARE SERVICES IN COUNTRIES OF THE REGION Health is at the centre of development in the Region. As such, there are increasing concerns within the Region, related to the issues of protecting the health of people as a fundamental right, and for increasing the access to health care. Health services need to be available close to the client and community, and to aim at increasing the accessibility of care to the poor, vulnerable and disadvantaged groups. In order to achieve this further, PHC services need to be strengthened in order to develop cost- effective interventions and build the necessary capacity. In light of the ongoing efforts towards increasing the access to TB/DOTS, scaling up anti-retroviral (ARV) treatment in line with the 3 by 5 strategy, and improving the coverage of treatment for opportunistic infections related to AIDS, it would be essential to further develop structures for CCHBHC services as part of the health systems of countries of the Region, which would specifically focus on human resources for health organization and management. Page 4

Model for Comprehensive Community and Home-based Health Care The demographic transition in countries of the Region means that there is an increase in life expectancy at birth, a decline in the population of 15 years and under, an increase in the ageing population (65 years and over) and that more people will be at higher risk of developing chronic and debilitating diseases associated with old age. Moreover the epidemiological transition within countries of the Region shows that there are persistent, emerging and reemerging communicable diseases, and that there is an increase in chronic noncommunicable conditions. This is observed in addition to cardiovascular diseases (CVD), cerebrovascular diseases, cancers and diabetes mellitus emerging as major causes of morbidity and mortality in some countries of the Region. Mental health problems and problems related to substance abuse continue to be serious public health concerns that often require long-term chronic care and support. This double burden of diseases requires health systems, more than ever, to deliver affordable, effective and easily accessible health services, and to incorporate disease prevention and health promotion into all programme activities. The need for community health services is great, because they offer an alternative to hospital care, specifically in the context of shortened hospital admissions unfolding in the Region as a way of reducing health expenditures. The CCHBHC services can provide continuum of care, and many basic care and support interventions can be carried out at home by formal and informal care-givers. Moreover, home is the setting of choice for most ill persons receiving care. The need for CCHBHC services is further emphasized by the increasing importance of providing care and support to PLHA and being able to implement the 3 by 5 strategy in the Region. Strategies for further developing the community and home-based health services are in place in several countries of the Region. For example, Sri Lanka has introduced a family health worker (public health midwife) for every 3 000 population (approximately 500 families) recruited by the government and trained in nursing schools for two years. In India the strategy for providing the necessary human resource for health (HRH) in support of community and home-based health services had been to ensure an auxiliary nurse midwife Page 5

Report of a Regional Consultation (ANM) per 5 000 population with two years of training, in recognition that the ANM was the main provider of basic health services. The main issue highlighted by all participating countries was the need to have solid HRH planning and management. Ensuring the necessary staffing at the peripheral level was seen as essential. To this end, capacity-building and training of front-line health workers was stressed and would include revision and updating of basic curricula for nursing/midwifery personnel and greater involvement and training of community volunteers. Moreover, the capacity within the intermediate health system, e.g. district or township-level health offices, would need to be strengthened in order to improve supervision and technical support to peripheral levels. 5. OVERVIEW OF THE SEARO CCHBHC MODEL AND FIELD-TESTING PROCESS The Regional Office initiated the development of a model as an interdepartmental collaboration to coordinate efforts in response to the needs for strengthening community- and home-based health care in countries of the Region. By early 2001 the draft CCHBHC model, developed by a multidisciplinary group at the Joint WHO Collaborating Center for Nursing and Midwifery Development, Mahidol University, Thailand, was ready. In August 2001 the first regional consultation was held to critically review the draft model. Then later in October 2001 a meeting of Principal Investigators from each of the four participating countries; Bhutan, Myanmar, Nepal and Thailand, was held at the Regional Office to finalize both the Model document and the Guideline document for field-testing. By November 2001 the introductory training for participating personnel from the four fieldtest countries had already been conducted in Ayutthaya Province, Thailand to have first-hand comprehensive experience on how integrated and continuous health care could be provided at community and home levels. During the following 10 months, starting from December 2001 September 2002, each of the countries carried out their field-testing. Page 6

Model for Comprehensive Community and Home-based Health Care The CCHBHC model was meant as a guide to countries to develop their own community and home-based health services and variations in the way countries would adapt and implement the model were expected. The CCHBHC model is based on the principles of holistic, integrated and continuous care. It acknowledges the contribution that individuals, groups and communities make in achieving and maintaining their health, and in managing illness throughout the lifespan. The model provides an overall framework for developing community and home- based health care as part of PHC and it includes systems and processes that can be adapted to meet the needs and priorities of local communities. In doing so, it builds on the existing health system structures and seeks to build capacities of the available health personnel for provision of health services. It is underpinned by partnership between health personnel and members of the local community. The Model emphasizes that care can be provided in various settings and by various people, including health professionals, care assistants and nonformal caregivers such as volunteers and family members. It includes primary, secondary and tertiary prevention. Specific diseases, health conditions or categories of clients will be targeted according to needs of local communities. Increasing the self-care ability of individuals, families and communities is part of the strategic thinking. The goal of CCHBHC is to increase the access to effective and efficient health services and health care in community and home settings, in order to contribute to morbidity and mortality reduction. The objectives are broadly divided into four categories: (1) Promoting healthy lifestyles and preventing illness; (2) Managing the consequences of illness; (3) Serving the needs of the vulnerable and underprivileged populations, and (4) Supporting informal caregivers. Page 7

Report of a Regional Consultation By expanding the focus of the existing system of PHC and including rehabilitation, curative and emergency care, the Model offers a holistic approach to addressing the health and illness continuum throughout the lifespan. The access to care will be through multiple entry points, and it is seen as essential that the care provision is cocoordinated and integrated. A key success to this is efficient and effective use of information by all those involved in the provision of services to patients whether based in health centres or hospitals, homes or in communities. The provision of care at a health centre or primary care unit should include: Outpatient clinic; Home visits; Care and active follow-up in emergency situations; Care and active follow-up of acute and chronic patients; Care and active follow-up of high-risk groups, and Health promotion and disease prevention programmes. The programme management is dependent upon the relationships and sense of ownership between the community and the relevant health providers such as the health centre. Intersectoral collaboration and support are necessary and can play an important role, e.g. with NGOs, and private sector. A District Leading Team should be established to undertake the management and coordination of the CCHBHC programme. Human resources for health are basically found among the existing personnel at health centre level who will work together with community volunteers. Health personnel should train and supervise the volunteers and family caregivers according to needs. Financial resources available for CCHBHC will largely depend on existing national policy. Monitoring and evaluation will follow the guidelines and contain both qualitative and quantitative indicators. Page 8

Model for Comprehensive Community and Home-based Health Care 6. EXPERIENCES IN FIELD-TESTING OF SEARO CCHBHC MODEL AND LESSONS LEARNED For the following review of each participating country s experiences of fieldtesting the CCHBHC model and lessons learned, a simple template format has been used to organize and present the data. 6.1 Bhutan The main objective of the CCHBHC model in Bhutan was to increase the accessibility to health, and to quality community health care. The implementation strategy for field-testing the CCHBHC model was in accordance with the guidelines. The field-testing took place in 2002 over a six-month period. Process The implementation was carried out as under: (A) Identification The main components of the CCHBHC programme were identified through village-level meetings conducted in each village within the catchment area of the two selected Basic Health Units (BHUs). These meetings, lasting up to 4-5 hours each, were conducted by the Principal Investigator (PI), supervisor and the participating health personnel, and they aimed, first of all, to advocate for the CCHBHC model and to negotiate and involve the beneficiaries from the very beginning. The meetings were held at either monasteries, outreach clinics or in the open field and were usually participated by an average of 30 persons in each meeting. During this consultative process, the following five core elements for the CCHBHC model emerged: (1) Personal and environmental hygiene and sanitation; (2) The under-5 growth monitoring and immunization; (3) Reproductive health, including safe motherhood; Page 9

Report of a Regional Consultation (4) Follow-up of chronic cases, and (5) Control of by-pass from BHU to hospital. The model was field-tested within the existing structures of both health system and community systems, and to this end, the Village Health Workers (volunteers) and community members came to play an important role in the preparatory as well as the implementing phase of the field-testing. The model appears to be appropriate in the specific country context of Bhutan, because not only is it integrated into the existing PHC structure, it has also helped strengthen it. Concrete suggestions for improving the management and service delivery of PHC were made during the community meetings and were mainly related to the need for strengthening: record-keeping in health centres; follow-up of chronically-ill community members, and referral system. These issues were to be addressed by the CCHBHC programme. (B) Preparations The briefing of Principal Investigator and training of participating health personnel took place according to plans. There was no specific training conducted for village health workers or community volunteers. However, as they were actively involved in preparatory meetings and problemidentification, the following actions were taken: A CCHBHC Orientation Workshop for the two Health Assistants and the Supervisor was conducted prior to their departure to Thailand to participate in the introductory training at Ayutthaya. Upon their return to Bhutan, an orientation workshop was conducted for the rest of the BHU team (four health personnel). Hands-on training of health personnel was also provided during the supervision visits later on in the process. (C) Coherence The relationship between objectives of the model and its actual implementation and results, appears to be consistent. However, there Page 10

Model for Comprehensive Community and Home-based Health Care apparently were some capacity constraints regarding the required preparation, training and supervision of health personnel and community health workers in relation to the CCHBHC concept and the related issues that were not addressed in the guidelines for field-testing. (D) Implementation system The implementation of the model builds on existing structures and available resources and does not seek to establish parallel structures. The field-testing period was divided into two phases: preparation and implementation. During the first phase, two BHUs in Punaka district were selected according to the criteria for the field-testing: Kabesa BHU and Samdingkha BHU. Both these BHUs have a number of out-reach clinics under them. The target group for the CCHBHC programme was the population living within the catchment area of the two selected BHUs. The health personnel working in these BHUs were the key players for conducting the field-testing; they comprised six careproviders and two supervisors; the caregivers were: two Health Assistants (two-year education after the 9th standard); two Auxiliary Nurse-Midwives (two-year education after the 9th standard), and two Basic Health Workers (one-year education after the 8th standard). The supervisors were: one District Health Supervisory Officer who is usually involved in supervising the BHUs and one selected Principal Investigator. Technical input to BHU personnel and community health workers was provided by the PI and the Supervisor. There is no reporting on whether families and clients received training and/or support for self-care at home. During the second phase, a number of changes were introduced in the working procedures at the BHUs and supervision was undertaken regularly. An interim assessment of the model was made in early July 2002, involving visits and discussions with personnel at two selected outreach clinics under the BHUs. Page 11

Report of a Regional Consultation The final assessment of the model, carried out by the PI who spent three days in each of the two selected sites, covered field observation (BHU and community), review of health information and documentation, interviewing the participating personnel, interviewing the supervisor, and focused group discussions with health workers and community members (E) Management structure of the model The guidelines suggest establishing a District Leading Team comprising health officers at the district level, health personnel at health centres and community leaders within the catchment area. This appears to have been achieved to some extent vis-a-vis the formation of the Village Development Committee to oversee sanitation and other health-related activities. However, there was no reporting of a clearly defined structure for the CCHBHC programme. Results First-level results (Knowledge gained): Changes in the knowledge and skills of participating health personnel was reported in terms of benefiting from the experience of field-testing the model. No knowledge assessment test was conducted following the introduction and training workshops. However, the orientation workshop and supervision appear to have been effective because they provided a basis for change in performance (see below). Second-level results (changes in individual performance): Changes were observed in individual performance of health personnel, e.g. they were polite and courteous towards patients and families, seeking detailed history and thus improving diagnosis capacities, collecting drugs for chronic patients and thus contributing to higher quality of care and increased confidence of patients. Health personnel were observed to organize their work better and to be more dedicated in filling out forms and maintaining schedules and registers. To this end, initiatives were taken by health personnel to improve the daily working procedures. Third-level results (change in organizational performance): A change occurred in organizational performance, primarily related to achieving an integration of the following services at the outreach clinic of the BHU: health Page 12

Model for Comprehensive Community and Home-based Health Care education, ANC, immunization, treatment of minor illness, follow-up of chronic cases and home visits for sanitation follow-up. Family folders were introduced in households and improvement effected in case management, primarily in relation to chronically-ill patients, e.g. related to medicine intake/distribution, personal record-keeping, registration and continuum of care. However, there was no reporting on the establishment of care/support groups within the community. Continuum of care was strengthened and planned discharge from the hospital was tried out. The following are some examples of improved organizational performance: New village health workers were selected in those places where there was a need for more support. A village Development Committee was formed to oversee sanitation and other health-related activities. A weekly schedule for BHU activities to be carried out was introduced including outreach activities for integrated services. Expanding the follow-up and long-term care at home to chronically-ill individuals. Regular update was done of family folders and registers of chronic patients, pregnant women and under-5 children. Follow-up was introduced for missed appointments. Intensified use of VHWs for follow-up and contacts with families. Drugs for chronic patients were collected and disbursed. Improved referral and communication between hospital and BHUs and vice versa. It appears that the field-testing process has been relatively effective in achieving progress and results in areas needing strengthening, that were identified during the first phase: record-keeping in health centres; follow-up of chronically-ill patients, and the referral system. Page 13

Report of a Regional Consultation Fourth-level results (Improvement in public health situation): It is beyond the scope of this field-testing to be looking for improvements in public health situation measured by prevalence/incidence rates. Relevance of the model as a capacity-building strategy for strengthening community-and home-based care and support The CCHBHC model seems to have been relevant in improving the health workers, and community health workers, understanding of PHC. Likewise, their performance in the delivery of basic health services also seems to have improved. Various initiatives have been taken to change and improve the daily working routines and practices. However, the specific delivery of care and support at homes, including supervision of family caregivers at home could probably be more emphasized and developed. Collaboration with the community as well as with the hospital has improved and certain coordination mechanisms established. Main Findings The main achievements and challenges related to the process of implementing the CCHBHC model are listed below. (A) Achievements The Community participated well in the provision of care, and the relationship between the community and health personnel was strengthened. Health personnel in BHUs changed their attitudes and improved the quality of work. Health personnel and the Supervisor found the model easy to follow and easy to adapt to the local context. The best help to health personnel was frequent supervision visits, and orientation and trainings on the model concept. Need-based health care to the community. Continuity of care improved. Better communication with community. Page 14

Model for Comprehensive Community and Home-based Health Care Improved referral system. Timely follow-up of patients. Efficiency in care delivery was achieved due to systematic and rational working procedures. (B) Challenges The knowledge of health personnel and the Supervisor regarding community and home-based care is limited; they could be better prepared for the model implementation. It takes time to change behaviour, belief and attitudes of people. The Supervisor and PI did not have frequent interaction with the community. Shortage of supervision and excess workload of Supervisor. Delayed release of funds for the field test. Insufficient time to prepare for field-testing. Shortage of staff at the BHU to cover large areas. The field-test period was too short and health personnel had to be absent for other training and duties during the field-testing period. Lessons learned Even though the concept and practice of community and home-based care already existed in the health system, the model has made these activities more integrated, comprehensive and better organized. The model contributes to increased accessibility to care, due to improved outreach, follow-up and referral. It also contributes to better quality of care, with existing resources, due to the integration of services and higher level of performance of the individual health personnel. However, it was reported that it was difficult to judge the applicability and usability of the model in other parts of the country, because the fieldtesting period was too short and only one district was selected. Page 15

Report of a Regional Consultation Continuous and supportive supervision was very much needed during field-testing, and is seen as the key to success in implementing the model. Recommendations for further improvement of the Model, and for its expansion in the country The following are the recommendations for further improving the model: 6.2 Myanmar (1) The field-testing should be carried out at additional sites within the country to provide more informed opinion concerning the applicability and usability of the model; (2) Health personnel and the Supervisor should have adequate and clear knowledge of community and home-based care, and of the CCHBHC model before the implementation, and (3) The Supervisor and PI should have more frequent interaction with the community. Community Health Care is one of the 12 broad health programmes included in the National Health Plan. Community and home-based care falls under the responsibility of the Department of Public Health, Department of Health, Ministry of Health (MoH), and the main objective of Community Health Care programme is to improve and expand the accessibility to primary health at the most peripheral level. The Self Care at Home programme was one of the important initiatives taken in this area in the past. The key health personnel involved in PHC are: Township Health Nurse; Lady Health Visitor; Midwife; Auxiliary Midwife, and Health Assistant. The Midwife is a multipurpose worker in Myanmar with a range of tasks and duties to perform including home visits. The implementation strategy for field-testing the CCHBHC model was in accordance with the guidelines. The field-testing took place from May to October 2002. Page 16

Model for Comprehensive Community and Home-based Health Care Process The implementation was carried out as under: (A) Identification The core services to be provided under the CCHBHC programme were identified by the investigation team in collaboration with health personnel selected for the field- testing during the orientation workshop. The core services were further discussed with families during the systematic and initial household visits to each family residing in the catchment area. Advocacy meetings were held at the central level to obtain support and commitment for the field-testing and at the local level to obtain commitment, motivation and participation of key stakeholders, e.g. local authorities, divisional and district health personnel, NGOs, schoolteachers and community members. The model appears to be responding to the basic priority health needs of the population, excepting the needs of PLHA. The CCHBHC programme has introduced activities in the ongoing working programme of the urban health centres, provided additional resources and technical input, and has been entirely built upon the existing health centre structure. However, the model assumes that there is capacity to also undertake the new functions and roles in relation to community and home-based care in addition to the existing tasks related to ANC, deliveries and postpartum care, vaccinations, growth monitoring, water and sanitation, etc. (B) Preparations The Principal Investigator attended the introductory training at Ayutthaya, Thailand arranged by the Regional Office. Upon his return to Myanmar, he conducted a three-day orientation workshop for selected health personnel and supervisors. The objectives of the workshop were achieved. The model documentation, including the tools for evaluation, were translated into the Myanmar language and distributed to participating health personnel and the district leading team. There is no reporting on training of community volunteers or others at this stage. Page 17

Report of a Regional Consultation (C) Coherence There seems to have been good consistency in implementing the model. The relationship between programme goal/objectives and actual programme implementation and service delivery was satisfactory. Accessibility to basic health services was increased. However, affordability remained a challenge although initiatives were taken to raise additional funds and expand the community cost-sharing mechanisms. (D) Implementation system The model was implemented as part of the existing urban health centre structure. However, some roles and responsibilities were added to the jobs of midwives and Lady Health Visitors, and new activities were introduced in addition to the ongoing activities of the centres. The CCHBHC model does not target specific groups of the population, health conditions or diseases, e.g. long-term and chronically-ill individuals and their families. In fact, it provides services to anyone in need of basic health care services. The field-testing period was divided into two phases: preparation and implementation. During the first phase the investigation team selected two urban health centres: Bago and Pyay, for field-testing the model. Both centres are located in Bago Division close to the capital Yangon. Both health centres fulfilled the selection criteria concerning adequate infrastructure, operational budget, staffing, material supply, and referral options. A total of 16 health personnel were selected for the field-testing of the model. The selected health personnel comprised: six lady health visitors and ten midwives. A total of eight supervisors were assigned to the two urban health centres (five medical officers, two township health assistant and one health assistant). As per their job descriptions the supervisors were usually involved in supervision of Basic Health Staff in the Division. The catchment areas were well defined and comprised two urban wards (areas), each estimated to have 5 000 population. An initial household visit was conducted by the midwives to each family residing in the two wards to obtain specific data and establish the family files. This approach appears to be very time and resource consuming and might not be realistic on a larger scale. Page 18

Model for Comprehensive Community and Home-based Health Care Community volunteers and members of the community were involved in the CCHBHC programme primarily from the perspective of identifying families and locating houses as well as drawing up the family files during the household survey. Some became involved in chronic care at home later on. In terms of the technical input provided, the PI facilitated the formulation of an action plan for the implementation of the model with clearly-assigned responsibilities. The main services provided for the CCHBHC programme were: Curative services at urban health centres Home care for curative services: Patients suffering from a broad range of illnesses and symptoms were sent to the health centre for treatment. Follow-up was conducted during home visits to ascertain the status of patients. Dialogue with the patient and family. Hospital services: Laboratory investigation. Referrals for patients needing admission. Health centre personnel visited patients at hospital. Supervision of involved health personnel was carried out as prescribed in guidelines for field-testing. Families and clients were supervised to some degree and encouraged to undertake self-care. Health education was also provided. Additional financial resources were mobilized for the existing revolving drug fund to cover expenditures for the poorest in the CCHBHC programme. The community cost-sharing scheme is well implemented in the country with funding from/through NGOs, community resource persons, donors and agencies. The investigation team headed by the PI conducted the final assessment and collected data from field observation, review of health information and documentation, interviewing the participating personnel, interviewing the supervisor, and through focus group discussions with (i) health workers and Page 19

Report of a Regional Consultation supervisors; (ii) clients, their families and non-formal caregivers, and (iii) community members, local authority and community volunteers. (E) Management structure of the model A District Leading Team was established, according to the guidelines for fieldtesting, as the managerial entity for the CCHBHC programme. The Team comprised two district health officers, two health centre personnel, two representatives from local administration and three major stakeholders (PI and two additional model staff). Their main responsibilities were: coordination; management, and ensuring completion of field-testing activities. This management structure does not appear to be part of the existing PHC structure at the township level. Results First level results: The participating health personnel expressed that they had learnt a lot from the orientation workshop, supervision and model practice. Knowledge test was not part of the guideline instructions. Second level results: Changes in individual performance of health personnel was reported in terms of being more confident and being able to establish open relationships with patients and their families during home visits and at community meetings. A majority of health personnel reported that they had started doing home visits more frequently, including visits to patients recently discharged from hospital. Some health personnel had experienced the results of their improved care and support to patients and families, e.g. self-care had improved and family caregivers were able to provide the necessary care for their ill family members at home. Third level results: Change in organizational practice was reported both in relation to facility-based services and community home-based care. A new system of patient registration, including card and files, was introduced both at health centre level and at home with the individual person e.g.: Personal book to be kept at home by the long-term or chronically-ill person; Page 20

Model for Comprehensive Community and Home-based Health Care Tickets to be kept by the acute or short-term ill person, and Family files to be kept at the health centre. This recording and updating of health events led to increased continuum of care and better quality of care. Approximately five-seven home visits were undertaken every week day during afternoon hours to a broad range of patient categories, including acutely-ill, recently-discharged-from-hospital, chronically-ill, and the elderly. The visits were made in addition to the regular home visits conducted by midwives and lady health visitors to attend to high-risk pregnancies, deliveries and postpartum care. Better coverage was established and people in need of care, especially rehabilitation at home, were identified. Family members and community volunteers were trained in care and support with focus on the chronically-ill; and those suffering from paralysis and/or diabetes. Community meetings were organized monthly to address the needs for long-term care and follow-up to high-risk groups. The effectiveness of the model in achieving the objectives was stated as relatively good. However, it would take more time and input from other sectors in order to achieve the objectives fully. Fourth level results: A decrease in morbidity and mortality due to dengue haemorrhagic fever and diarrhoea was recorded as compared to data recorded during the same time last year. However, it is difficult to determine whether this decrease is caused by the services provided vis-a-vis the CCHBHC model or other factors external to the model field-testing activities. Relevance of the model as a capacity-building strategy for strengthening community-and home-based care and support Both health personnel and community members expressed that their general knowledge and awareness of health promotion, health prevention and community home-based care had increased. The model had helped establish a better dialogue between the health facility and the community, and had contributed to better health seeking behaviours. Page 21

Report of a Regional Consultation During the community meetings, priority areas and issues that needed improvement had been identified and proper actions and solutions were discussed. Cooperation had also been established with other sectors like the municipal committee and education department. The model has helped bring focus on ways of more rational utilization of basic health staff at the health centre level to deliver primary health care and home-based care in particular. To this end, the involvement of community volunteers and non-formal caregivers could be explored to much higher potential. Main findings (A) Achievements The model documentation is easy to understand and follow. Participating health personnel expressed that they had learnt a lot from the model field-testing. Some cost-sharing mechanisms were tried out in the community, both with respect to medicines and transportation, as well as at the hospital for medicines. Gatherings at the meeting hall were organized for children under five who had missed immunization days, growth monitoring of children and health education to mothers, including birth spacing and antenatal care. An increase in health clinic attendants was reported during the months of the field-testing, a higher number of timely referrals to hospital took place and a better follow-up to ill patients at home was performed. (B) Challenges Health expenditures are high, and a majority of clients have difficulties finding sufficient funds to cover medicines, doctors fees, transportation etc. In some cases hospitals and communities can support the poorest to meet health expenditures. Page 22

Model for Comprehensive Community and Home-based Health Care The workload of health centre personnel is high and should be more equally distributed among different categories of public health staff. Further to this the demand for reporting and filling out forms needs to be reduced and better coordinated. The coverage of CCHBHC services was pointed out as a main challenge. Additional health personnel are needed in order to utilize this model approach in the future. A suggestion was made for a more realistic coverage and workload; 200 households per one health personnel. The CCHBHC model needs to target priority groups, diseases and/or conditions in order to avoid overload, e.g. request for including home visits during minor illnesses. An optimum utilization of scarce resources is necessary. Limited understanding and knowledge among communities, families and health personnel of the community home-based care concept, and of health promotion and disease prevention. Training modules and other resource materials are needed for upgrading of skills and for capacity-building. Lessons learned The CCHBHC model field-testing meant that there was more efficient use of drugs at the health centre, which led to an increase in the utilization rate, and in the confidence and credibility in the relationship between health personnel and patients. Although cost-sharing schemes exist at health centres, and revolving drug funds are used for replenishment of drugs, it was found that more funds were needed to keep up with the demand for cover medicines for the less privileged. The community meetings gave an opportunity to discuss the prevailing issues like control of dengue haemorrhagic fever; diarrhoea control measures; sanitary latrines; transportation for emergencies, and fund-raising for replenishment of medicines. They also brought about a sense of ownership and shared responsibility within the community. Page 23

Report of a Regional Consultation 6.3 Nepal The systematic household survey conducted in phase 1 in the catchment area is not reported to be necessary and in some cases redundant. Some families are wealthy and have no health problems or are not interested in home visits, while others expressed that systematic visits were too time consuming and required different staffing. Advocacy for the model is essential for successful implementation. Local administration, NGOs and hospital staff are interested in collaboration, if benefits and gains are clearly recognized. The use of a home-based care kit containing medicines and items for basic care would make the work of health personnel more effective. Patients would also perceive health personnel differently, while families and communities, and health personnel would gain more credibility. Home visits are not an effective way to do under-5-years-children check-ups, because children of working parents are often not at home, and thus not available for under-5-year check-ups, because they are following parent to work place. Recommendations for country adaptation of the model and for its further implementation (1) Health personnel should be assigned to cover only a defined catchment area (e.g. 200 households/health personnel) and use community volunteers to higher potential; (2) Model should be as simple as possible, and reconsider the purpose of systematic household visits for initial data collection; (3) Criteria for home visits should be more selective and focused on target groups, and (4) Study tours should be arranged for health personnel to get more knowledge from other experiences. Ecologically the country is divided into three regions from east to west; the mountain region constitutes 35%, the hill region 42% and the terai (lower plains) 23%. An estimated 90% of the population lives in rural areas. Page 24

Model for Comprehensive Community and Home-based Health Care The National Health Policy of 1991 has brought structural changes to the community level to increase the access to basic health services by ensuring at least one health unit in each VDC covering 4 000-5 000 population, and within one hour walking distance. The health worker ratio per population is minimum 1/1000-2000 and one primary health care centre (PHCC) should be opened in each of the 205 constituencies of the country. Nepal has adopted an integrated health service delivery system at the district level down to the sub-health posts and identified the main components of this health service delivery package. The country had no tradition for home visits and home- based care prior to the CCHBHC model field-testing. The main objective of the CCHBHC programme in Nepal was to increase the accessibility to health services, and to quality community health care. The implementation strategy for field-testing the CCHBHC model was in accordance with the guidelines. The field-testing took place in 2002 during a four-month period. Process The implementation was carried out as under: (A) Identification The main components of the CCHBHC programme were identified during four CCHBHC orientation workshops conducted for all stakeholders of the CCHBHC programme at different levels. These orientation workshops also clarified the goal and objectives and principles and strategies of the CCHBHC Programme. (Refer to 7.3.2. Preparations). The core elements of the CCHBHC programme correspond with Nepal s main components of the integrated health services delivery package: treatment of common diseases and injuries reproductive health expanded programme on immunization Page 25

Report of a Regional Consultation leprosy control and TB integrated management of childhood illnesses nutrition and health education and control of diarrhoeal diseases and ARI STD/HIV/AIDS Vector-borne diseases The model appears to be appropriate in the specific country context of Nepal, because it is integrated into the existing PHC structure and has helped strengthen the utilization of PHCC and the demand for home-based care services. (B) Preparations The Bishnu Devi Primary Health Care Centre (PHCC) at Kirtipur, Kathmandu District, was selected according to the criteria for the model field-testing. The urban PHCC has 19 wards and a catchment area with a population of 47 515. Four wards with 240 households were selected within the catchment area of the PHCC. The Director-General, Health Services, conducted a meeting for participants who attended the initial CCHBHC training workshop in Ayutthaya, Thailand, August 2001, and for health personnel at the selected PHCC, local community leaders, the school principal and NGOs, in order to gain consensus for launching the CCHBHC field-testing. Two medical doctors, who were familiar with supervision, were selected as supervisors. They participated in the CCHBHC training workshop. Four CCHBHC orientation workshops were conducted by the Investigation Team during January and February 2002, respectively for health personnel of the PHCC, community members, ward members and the health committee (total participation:19); the second workshop was conducted for health personnel at the Central and District Region Health Office in Kathmandu district (total participation: 34); the third workshop was conducted for health personnel at sub-health posts, MCH workers and village health workers (VHWs) (total participation: 13); the fourth workshop was Page 26